The lack of coexisting pain symptoms in patients with burning mouth syndrome (BMS) suggests that BMS depends on specific mechanisms, likely at the trigeminal level, according to a study published in the Sept. 22 issue of PLOS One. Its authors said the study is the first systematic review to determine whether BMS is associated with other pain syndromes and to analyze head and body sensitivity in patients with BMS.

Patients with BMS experience chronic, spontaneous, and unremitting burning pain in the tongue or other parts of the oral cavity without any identifiable local lesion or laboratory finding. Its prevalence increases with age and the group most afflicted is women from 60 through 69 years of age.

Although recent evidence suggests that the problem is a peripheral or central neuropathic disorder, the cause of these neuropathic changes remains unidentified, wrote the study’s authors, who are from France and Chile. Previous studies have suggested that BMS is a pain symptom and therefore associated with other cephalic or extracephalic pain symptoms. Authors of other recent investigations proposed that any orofacial pain without organic cause belongs to a group of central sensitivity syndromes that are produced by central sensitization and therefore coexist with other chronic pain syndromes, such as fibromyalgia and visceral pain.

Considering that the pathogenesis and etiology of BMS are still unknown and with an eye toward learning if BMS may share common mechanisms with other chronic pain syndromes, the study’s authors sought to learn if there was an association between BMS and other types of chronic pain disorders.

They searched the published literature for BMS studies that also assessed the presence of other pain symptoms or quantified sensory function. Studies looking for a link between BMS and other types of pain were included. Pain was classified into 2 main groups according to their location: cephalic (temporomandibular disorder, headaches, atypical facial pain, trigeminal neuralgia) and extracephalic (abdominal, genital, back, widespread musculoskeletal (fibromyalgia) and joint pain). Quantitative sensory testing measurements were classified as cephalic skin or upper-limb skin measurements.

Results showed that the co-occurrence of BMS with other pain symptoms was assessed in less than 1% of studies. Of the 1,512 articles identified, 12 (633 patients) met all criteria for examining co-existing pain symptoms. The average age of the patients in these studies was 60.9 years, and 85% were women.

The authors of 9 (384 patients) studies conducted quantitative sensory testing. They found no or inconsistent evidence of abnormal cutaneous cephalic and extracephalic somatosensory sensitivity in patients with BMS.

There was no evidence of an association between BMS and other pain symptoms, and patients with BMS did not display clear somatosensory patterns, the authors said in the conclusion. They said the lack of co-occurring pain symptoms with BMS suggested it was dependent on specific mechanisms, likely at the trigeminal level. “By challenging several previous conclusions, this review clarifies the current state of knowledge about BMS,” the authors said.

Scientists at the National Institutes of Health, National Cancer Institute focused on a possible association between chronic sinusitis and head and neck cancer (HNC) with a case-cohort study of people enrolled in Medicare. They published their findings online Sept. 8 in JAMA Otolaryngology—Head and Neck Surgery.

Considering the possibility that inflammatory changes caused by chronic sinusitis may increase the risk of developing HNC or that sinusitis may be a marker of a local immunodeficiency that increases susceptibility to virus-induced cancers, they examined the risks of developing HNC in people with and without chronic sinusitis.

The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database offered a sample group of interest owing to its large longitudinal database of people in the United States who were older than 65 years, a group in which more than 40% of HNCs occur. From the study’s source population of 9.4 million people living in SEER areas from 2004 through 2011, the scientists compared a 5% random subcohort of 483,546 beneficiaries with 21,716 people from the entire source population who developed HNC.

Chronic sinusitis, defined as sinusitis persisting for longer than 12 weeks, was identified by means of diagnosis codes submitted to Medicare from hospital, physician, and outpatient claims. To increase the definition’s positive predictive value, 1 hospital or 2 physician or outpatient claims at least 30 days apart were required to define chronic sinusitis.

Characteristics of people in the subcohort group, with and without chronic sinusitis, were compared. People who received a diagnosis of chronic sinusitis were considered exposed and followed until they developed a cancer of interest, migrated out of a SEER area, discontinued Medicare coverage, entered a health maintenance organization, died, or survived through the end of the follow-up period. In evaluating risk of developing overall and specific types of HNC, scientists counted only a person’s first cancer diagnosis during follow-up. They distinguished between short-term and long-term associations, determining that short-term sinusitis symptoms may have been due to symptoms caused by an undiagnosed HNC.

They noted that 3.9% of the 483,546 people in the random subcohort group developed chronic sinusitis. Chronic sinusitis was associated with an increased risk of developing HNC. However, most of the increased risk was within 1 year of the diagnosis of chronic sinusitis. Any associations were greatly reduced after the first year. All 3 HNC subtypes—nasopharyngeal cancer (NPC), human papillomavirus–related oropharyngeal cancer, and nasal cavity and paranasal sinus cancer (NCPSC)—had a cumulative incidence of less than 0.07% 8 years after a diagnosis of chronic sinusitis.

However, within 1 year after diagnosis, the authors found that chronic sinusitis was strongly associated with NPC and NCPSC. “In contrast, the associations over longer intervals were weaker, suggesting that sinusitis-related inflammation and/or immunodeficiency play, at most, a minor role in the development of these cancers,” the authors concluded.

Potential factors accounting for the increased risk of receiving a HNC diagnosis within 1 year of diagnosis of chronic sinusitis included the greater likelihood of undergoing medical evaluation—including diagnostic imaging—of the head and neck, which would increase the probability of identifying an indolent HNC tumor (surveillance bias) or the potential for an undiagnosed HNC being initially misdiagnosed as chronic sinusitis or causing chronic sinusitis (reverse causation).

For NCPSC, scientists observed a significant association up to 3 years after a diagnosis of chronic sinusitis. “One possibility is that chronic sinusitis, especially if present over an extended period, could induce genetic damage to the epithelium lining these spaces, which, when cumulative, could promote carcinogenesis,” the authors said in the discussion.

The authors also noted previous research that suggested that chronic sinusitis may have been a marker of immunodeficiency, the potential effect of which would become evident years after the original chronic sinusitis diagnosis, particularly for infection-related HNCs, which developed decades after human papillomavirus or Epstein-Barr virus infections. However, their research found only modest and insignificant associations with infection-related HNC, suggesting that sinusitis-related inflammation and immunodeficiency do not play large roles in promoting the early or intermediate carcinogenic stages of infection-related HNC.

Researchers concluded that the increase in HNCs diagnosed within 1 year of chronic sinusitis diagnosis could be explained in large part by surveillance bias, reverse causation, or diagnostic confusion. “Whereas an etiologic contribution of sinusitis-related inflammation or immunodeficiency to HNC cannot be excluded, this study suggests that they do not play a large role in promoting the early or intermediate carcinogenic stages of HNC”.

Customized interventions that may increase human papillomavirus (HPV) vaccination in U.S. adolescents were discussed by a team of scientists exploring the prevalence of and factors associated with provider recommendations for the vaccination. They published their findings in the November issue of Journal of Adolescent Health.

Despite the fact that the Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommends that adolescents receive this vaccination, the rate of use of this vaccine has been suboptimal compared with other routine vaccinations in adolescents, the authors reported. “Therefore, increased efforts are needed to determine and address factors associated with vaccine uptake in order to meet the Healthy People 2020 objective of achieving 80 percent HPV vaccination completion rates for boys and girls aged 13-15 years of age,” they said.

Considering that previous evidence showing that provider recommendation of HPV vaccine is 1 of the most important and influential predictors of vaccine use, missed clinical opportunities remain the most important reason for lower rates of vaccine use, authors said. Determining that the finding indicates the need to better understand factors associated with provider recommendation of the vaccine at both the provider and patient level, they conducted a study analyzing data from the National Immunization Survey—Teen 2014, which reported on 34,478 adolescents aged 13-17 years. They aimed to determine the prevalence of provider recommendation and to examine the impact of adolescent and parent sociodemographic characteristics on it.

Among the results, the team found that overall 72.6% of girls and 51.8% of boys received a provider recommendation for receiving the HPV vaccination.

However, recommendation rates were not uniformly distributed across adolescents’ sociodemographic characteristics, which included age; sex; race/ethnicity; mother’s age, marital status, and education level; number of children in family; poverty status; census region; number of health care providers; and number of physician visits in the past year. Adolescent girls had 2.57 times higher chance of receiving a provider recommendation for the vaccine than did adolescent boys. Prior evidence showed that the main reason parents reported for not vaccinating their adolescent boys was the lack of provider recommendation. The authors noted that the lower prevalence of recommendation for adolescent boys indicated provider misconceptions about HPV risks.

Among other disparities in provider recommendation of HPV vaccination based on sociodemographic characteristics of adolescents and their patients, scientists found that older teenaged girls (17 years) were more likely to receive a recommendation for the HPV vaccine than were younger ones (13 years). This goes against ACIP guidelines, which state that 11- through 12-year-olds are the ideal age for routine vaccination and that the efficacy of HPV vaccine is at its greatest before the recipient engages in sexual activity.

Adolescent boys and girls residing in the South had lower odds of vaccine recommendation compared with those living in the Northeast, Midwest, and West. The authors noted previous research showing that primary care physicians were less likely to recommend the vaccine if they were family physicians, practiced in rural areas, or practiced in the South. Family physicians are the most likely providers to see adolescents in the South, which has the largest proportion of rural areas.

The scientists also found that the type and purpose of a patient’s physician visits played an important role in determining the likelihood of receiving the vaccine. Overall, the vaccine was routinely recommended if it was a well-child or preventive care visit and less often if it was for acute care or an injury.

Study findings suggest that intervening at the provider level and addressing disparities and barriers to vaccination promotion are attainable tasks in meeting HPV vaccination objectives, the authors said.

A multidisciplinary team of scientists in Europe and Australia who examined the effectiveness of smoking cessation interventions in patients with head and neck cancer (HNC) found that extended cognitive behavior therapy (CBT) coupled with pharmacotherapy may have been effective in improving cessation rates and smoking-related behaviors. They published their findings in the September issue of BMJ Open.

Despite evidence showing improvements in the prognosis of patients with a cancer diagnosis after smoking cessation, previous research had shown that at least one-third of patients with HNC continued to smoke after diagnosis. In addition to a 2-fold increase in complete response to radiation therapy, abstinence from smoking by patients with cancer has been associated with less pain and higher quality of life. Thus, the aim of the scientists was to examine effectiveness of interventions on smoking cessation rates in these patients.

To explore, scientists analyzed trials reporting smoking cessation among patients with HNC who experienced part of the intervention in a health care setting. Of 5,167 citations, 3 studies met the inclusion criteria of the review: 2 randomized controlled trials (RCTs) and 1 non-RCT. All 3 studies were conducted in the United States. Two targeted solely smoking cessation, whereas the third targeted multiple risk behaviors of smoking, alcohol use, and depression.

Interventions were delivered by health care providers and consisted of CBT, self-help material, and telephone counseling or were combined with a pharmacologic component (nicotine replacement therapy [NRT]), varenicline, or bupropion. In all 3 studies, the control group received usual care, which ranged from information about the risks of continued smoking and the benefits of cessation to providing handouts for resources to referral for smoking cessation treatment. The follow-up period ranged from 1 to 12 months.

Of the 3 studies, authors found that only 1 showed significantly higher quit rates than those in the control group. The RCT tested a tailored smoking, alcohol use, and depression intervention with CBT that addressed smoking, alcohol use, and depression, used a patient workbook and telephone counseling by nurses in combination with NRT or bupropion (and antidepressants for depression) to target comorbid conditions (for example, smoking, alcohol use, and depression). Six months after the intervention, 47% of the 136 patients with HNC who had smoked in the past 6 months at baseline reported quitting versus 31% in the control group who were receiving usual care.

In the discussion, the authors said that the small number of eligible studies showed the lack of robust smoking cessation intervention research conducted among patients with HNC, a group for which ceasing tobacco use is particularly important.

The authors’ research underscored previous evidence showing that relatively brief interventions by health care providers were ineffective. The only study to find statistically significant differences between intervention and control groups regarding cessation was high intensity and multicomponent, with up to 11 telephone counseling sessions that targeted multiple risk behaviors with CBT and pharmacotherapy.

“This finding suggests that low intensity or single intervention components that are sufficient for other patient groups may not be adequate to achieve cessation among patients with HNC characterized by long histories of heavy smoking and high nicotine dependence,” the authors said.

Among the conclusions, they called for further studies with strong methodological quality and standardized outcome measures in this population to guide development of smoking cessation programs.

Other CE programs include: “Extra-nodal Lymphomas of the Head and Neck” with Judith Ferry, MD, “Newly described entities in Head and Neck Pathology” with Justin Bishop, MD, and the Founders Memorial Seminar – “Whose WHO in Head and Neck Pathology” with Lester Thompson, MD. For up-to-date information, click here.

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